I, the parent or legal guardian of the above named, allow him / her to attend VBS. I recognize the risk involved in activities and will not hold Coventry CoB, its staff or volunteers, responsible for any personal injury that might occur to my child while participating in this program. I authorize a staff member or volunteer from the church to seek and obtain such emergency or medical services for my child as deemed necessary at the time.

Parent/Guardian #1 Address *

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Parent/Guardian #2 Address (IF DIFFERENT) *

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Emergency Contact #1 Name *

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Emergency Contact #2 Name *

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Name(s) of those who may pick up your child / children *

Church you regularly attend *

Photo Usage *

I give my permission for my child/children to appear on Coventry Church of the Brethren’s website and/or facebook page.I DO NOT give my permission for my child/children to appear on Coventry Church of the Brethren’s website and/or facebook page.